STATE OF TENNESSEE DAVIDSON COUNTY CHANCERY COURT

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					STATE OF TENNESSEE                                            SUBPOENA                                         CASE FILE NUMBER
DAVIDSON COUNTY                                           (ORDER TO APPEAR)
CHANCERY COURT
                                         Medical Records (See HIPAA Requirement Below)
PLAINTIFF                                                        DEFENDANT


TO: (Name, Address & Telephone Number of Witness)
                                                                                                  Method of Service:

                                                                                                  □ Davidson Co. Sheriff
                                                                                                  □ Personal Service
                                                                                                  □ Out of County Sheriff



You are hereby commanded to appear at the time, date and place specified for the purpose of giving testimony. In addition, if indicated, you
are to bring the items listed. Failure to appear may result in punishment by fine and/or imprisonment as provided by law.

TIME                             DATE                              ITEMS TO BRING:



PLACE      Chancery Court, Part ________
           1 Public Square
           Fourth Floor
           Nashville, Tennessee 37201
                        (OR)




                                                                   ___ Additional List Attached

This subpoena is being issued on behalf of
____ Plaintiff ____ Defendant                                      DATE ISSUED
Attorney: (Name, Address & Telephone Number)                       Cristi Scott, Clerk and Master

                                                                   By:
ATTORNEY’S
SIGNATURE:

AGENT:
                                                                                                    Deputy Clerk and Master
AGENT’S
SIGNATURE:



                                                     HIPAA NOTICE

       A copy of this subpoena has been provided to counsel for the patient or the patient by mail or facsimile on the ________ day

of _______________, 20 ____ so as to allow him/her seven (7) days to:

      (A) serve the recipient of the subpoena by facsimile with a written objection to the subpoena, with a copy of the notice by
facsimile to the party that served the subpoena, and

     (B) simultaneously file and serve a motion for a protective order consistent with the requirements of T.R.C.P. 26.03, 26.07
and Local Rule § 22.10.

       If no objection is made within seven (7) days of the above date, you shall process this subpoena and produce the documents
by the date and time specified in the subpoena. The signature of counsel or party on the subpoena is certification that the above
notice was provided to the patient.


                                             ADA Coordinator, Cristi Scott (862-5710)
                                                      RETURN ON SERVICE
 Check one: (1 or 2 are for the return of an authorized officer or attorney; an attorney’s return must be sworn to; 3 is for
 the witness who will acknowledge service and requires the witness’s signature.)

     1. ___ I certify that on the date indicated below I served a copy of this subpoena on the witness stated above by

     _____________________________________________________________________________________________

     2. ___ I failed to serve a copy of this subpoena on the witness because


 ________________________________________________________________________________________________

    3.    ___ I acknowledge being served with this subpoena on the date indicated below:


 Sworn to and subscribed before me on this ____ day of       DATE OF SERVICE
 _______________________, 20 ___.

 Signature of ___ Notary Public or ___ Deputy Clerk
                                                             SIGNATURE OF WITNESS, OFFICER, ATTORNEY OR
                                                             ATTORNEY’S AGENT
 My Commission Expires:



Submit three:                Original, Witness Copy & File Copy